Sleep Disorders in Spinal Cord Injury: Challenges and Opportunities

Transcription

1 Sleep Disorders in Spinal Cord Injury: Challenges and Opportunities JENNIFER L. MARTIN, PHD RESEARCH SCIENTIST AND PSYCHOLOGIST VA GREATER LOS ANGELES HEALTHCARE SYSTEM ASSOCIATE PROFESSOR DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA M. SAFWAN BADR, MD MBA PROFESSOR AND CHIEF PULMONARY, CRITICAL CARE AND SLEEP MEDICINE JOHN D. DINGELL VAMC DEPARTMENT OF MEDICINE WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE

2 Disclosures Presenters have no interests to disclose. PESG and PVA staff have no interests to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with PVA. PESG, PVA, and all accrediting organization do not support or endorse any product or service mentioned in this activity.

3 Learning Objectives At the conclusion of this activity, the participant will be able to: 1. Identify common sleep difficulties and sleep disorders faced by individuals with SCI 2. Understand gaps in the existing literature regarding methods to improve sleep quality and treat sleep disordered breathing among SCI patients 3. Describe the challenges and opportunities in identifying and managing sleep disorders in SCI

4 Poor Sleep Quality in SCI: Causes, consequences and the need for interventions JENNIFER L. MARTIN, PHD RESEARCH SCIENTIST AND PSYCHOLOGIST VA GREATER LOS ANGELES HEALTHCARE SYSTEM ASSOCIATE PROFESSOR DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA

5 Poor sleep quality in SCI Prevalence of poor sleep quality Predictors of poor sleep Sleep disorders and other factors Sleep disordered breathing (discussed later) Circadian factors Insomnia disorder Interventions Melatonin agonist Cognitive and behavioral strategies?

6 Most SCI Patients have Poor Sleep Quality Sankari et al., Spinal Cord. 2015

7 Sleep Quality Ratings in SCI vs. MS SCI (n=581) MS (n=1,096) F (p-value) MOS-Sleep Scale domain Mean (SD) Mean (SD) Sleep disturbance 38.8 (27.4) 35.6 (25.1) 4.93 (.03) Snoring 36.1 (34.2) 31.8 (32.2) 1.80 (.18) Respiratory problems 14.3 (24.2) 15.7 (23.8) 0.02 (.89) Sleep quality 6.6 (1.8) 7.1 (1.5) (<.01) Sleep adequacy 51.4 (26.4) 48.7 (26.6) 1.74 (.19) Daytime somnolence 38.0 (23.9) 40.4 (24.8) 0.09 (.77) Sleep problems index (20.6) 38.5 (19.5).23 (.63) Fogelberg et al., JCSM 2016

8 Predictors of Poor Sleep in Veterans with SCI (n=822) OR (95% CI) P-value Race (white vs. other) 1.43 ( ).04 Education (> some college vs. other) 1.15 ( ).38 Living alone (vs. with other) 1.06 ( ).74 Duration of SCI 0.99 ( ).40 Current smoker 1.19 ( ) <.001 Alcohol problems (past year) 4.19 ( ).03 Hypertension 1.34 ( ).07 High cholesterol 0.88 ( ).45 Diabetes 0.96 ( ).84 Asthma 2.37 ( ).03 COPD 1.93 ( ).05 Weight gain 2.06 ( ) <.001 LaVela et al., Spinal Cord. 2012

9 SCI patients with intermittent pain (n=42), chronic pain (n=99), and without pain (n=50) Noorbrink Budh et al., Spinal Cord Basic Nordic Sleep Questionnaire Items (range 1-5)

10 Circadian rhythms Day Night Day Night SLEEP SLEEP

11 Circadian patterns of melatonin and cortisol in cervical SCI (n=22) versus controls (n=22) Serum Melatonin Levels Serum Cortisol Levels * * SCI patients had higher melatonin levels in the morning (when melatonin levels are typically low), and higher cortisol levels at midnight (when cortisol levels are typically low) compared to controls. Fatima et al., Spinal Cord. 2016

12 SCI and circadian core body temperature rhythms (n= 7 tsci; 7 csci; 8 controls) Cervical SCI 5-hr phase-advanced circadian temperature rhythm trough time Highest nocturnal mean core temperature More variable relationships between physical activity and core temperature * Thijssen et al., chronobiology int 2011

13 Ramelteon (melatonin agonist) to improve sleep in tetraplegia (crossover RCT; n=8) Zeitzer J Spinal Cord Med 2014

14 Insomnia disorder in SCI? 3 or more nights per week with Poor Sleep + Daytime consequences 3 months or more DSM-5 (APA, 2015) and ICSD-3 (AASM 2013) diagnostic criteria for Insomnia Disorder

15 Impact of a brief sleep intervention for Veterans with functional impairments Randomized controlled trial (N=21 per group) 4-week intervention with a health educator Sleep education, sleep compression, stimulus control, sleep hygiene. Brief sessions (~30 minutes) Simple sleep diary Control group: sleep education and information only. Assessments Baseline, Post-treatment, 4-months follow-up Sleep, fatigue, depression, quality of life Wrist actigraphy measurement of sleep parameters VA Rehabilitation Research and Development Service IIR RX000135

16 Actigraphically-estimated sleep Sleep percent increased Time awake at night reduced Number of awakenings reduced Treatment effects shown as treatment minus control All effects significant at post-treatment (p<.016) and 4-month follow-up (p<.035) VA Rehabilitation Research and Development Service IIR RX000135

17 Subset of patients who were wheelchair bound (n=6/group) VA Rehabilitation Research and Development Service IIR RX000135

18 Challenges and opportunities Individuals living with SCI have significant sleep disruption, exacerbated by pain and other symptoms High rates of sleep disordered breathing play in important role and the benefits of treatment of SDB on sleep quality requires further attention While there is evidence for circadian rhythm dysregulation, insufficient data exist to suggest this as a first-line therapeutic approach

19 Challenges and opportunities Studies have not addressed the effectiveness of nonmedication interventions, such as cognitive-behavioral therapies, to improve sleep. This represents an opportunity for intervention development and treatment outcomes research Adaptation of CBT for insomnia (CBT-I) for SCI patients Combine sleep quality interventions to improve adherence to treatments for SDB (PAP therapy) Develop novel approaches and assistive technologies that can be integrated into routine care, to improve sleep quality in SCI

20 Sleep Disorders in Spinal Cord Injury: Challenges and Opportunities M. SAFWAN BADR, MD MBA PROFESSOR AND CHIEF PULMONARY, CRITICAL CARE AND SLEEP MEDICINE JOHN D. DINGELL VAMC DEPARTMENT OF MEDICINE WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE

21 Not just your uncle anymore!!

22 The continuum of collapsibility Normal Snorer OSA

23 Symptoms of Sleep Apnea Habitual snoring Excessive daytime sleepiness Instruments? Witnessed apnea Multiple nocturnal arousals Headache GERD?

24 Polysomnography

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26 EKG Exhale Airway obstructs Airway opens Airflow Thoracic effort Abd. effort Inhale Effort gradually increases Paradoxing Paradoxing Ends SAO2 Blood oxygen levels reduce to < 3% of basline value Obstructive Apnea A complete blockage of the airway despite efforts to breath. Notice the effort gradually increasing ending in airway opening.

27 Central Apnea

28 Sleep-Disordered Breathing Prevalence Young et al. 1993; 328:

29 Positive Airway Pressure Therapy (PAP) 29 Positive airway pressure maintains airway patency Titration >95% effective CPAP therapy

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31 Sleep Disordered breathing Spinal Cord Injury Higher risk of sleep disordered breathing (SDB) Prevalence : 27% to 62%, higher in cervical SCI SDB and chronic SCI are associated with increased adverse cardiovascular consequences. Does SDB contribute to increased cardiovascular mortality in SCI patients?

32 SDB prevalence in chronic SCI # patients Level # (%) RDI >15 Short et al (1992) 22 (20 M) T10-above 6 (25%) + 2 central Flavell et al (1992) 10 (10 M) Cervical 3 (30%) O2sat>10% <90% McEvoy et al (1995) 40 (37 M) Cervical 9 (22%) OSA+ mixed Klefbeck et al (1998) 33 (28 M) Cervical 15% (ODI >4%)+ PB Burns et al (2000) 20 (20 M) L1-above 8 (40%) Stockhammer (2002) 50 (40 M) Cervical 24 (48%) Berlowitz et al (2005) 30 (25 M) Cervical 62% (RDI>10) Ludec et al (2007) 41 (41 M) Cervical 22 (53%) Home study Sankari et al (2014) 26 (16 M) T6 -above 77% (AHI >5)

33 Fig 1 c Berlowitz et al., Arch Phys Med Rehabil 2005 Archives of Physical Medicine and Rehabilitation , DOI: ( /j.apmr ) Copyright 2005 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Terms and Conditions

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35 Characteristics of chronic SCI

36 Characteristics of chronic SCI Supine position affect lung volume

37 Sleep Disordered Breathing in Chronic SCI 1/4 Cervical SCI had Cheyne-Stokes Respiration

38 Characteristics of chronic SCI SDB is very common Level dependent

39 Characteristics of chronic SCI SDB is very common Level dependent

40 Simplified Diagnostic Approach in Individuals With Spinal Cord Injury Adults with C1-T6 SCI (N=81). Performance of an unsupervised home sleep apnea test + transcutaneous PCO2 monitoring Nocturnal hypercapnia was present in 28% and oxygen desaturation in 18.3%. Unsupervised home sleep apnea testing with transcutaneous capnography effectively identifies sleep-disordered breathing and nocturnal hypercapnia in individuals with SCI. Fig 2. Scatterplots of PSG results for all study individuals, expressed as number of events per hour of monitoring time: (A) O-AHI; (B) nonspecific hypopnea events (events/h); (C) CSA events (events/h). Kristy A. Bauman, Armando Kurili, Helena M. Schotland, Gianna M. Rodriguez, Anthony E. Chiodo, Robert G. Sitrin Simplified Approach to Diagnosing Sleep-Disordered Breathing and Nocturnal Hypercapnia in Individuals With Spinal Cord Injury Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 3, 2016,

41 Simplified Diagnostic Approach in Individuals With Spinal Cord Injury Fig 3. Scatterplots of tc-pco2/spo2 monitoring results for all study individuals: (A) duration of hypercapnia, expressed as percentage of monitoring time with Pco2=50mmHg; median and interquartile range are shown; (B) maximum Pco2 (mmhg) detected during the mo... Kristy A. Bauman, Armando Kurili, Helena M. Schotland, Gianna M. Rodriguez, Anthony E. Chiodo, Robert G. Sitrin Simplified Approach to Diagnosing Sleep-Disordered Breathing and Nocturnal Hypercapnia in Individuals With Spinal Cord Injury Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 3, 2016,

42 Identification and treatment of sleep-disordered breathing in chronic spinal cord injury The objectives of this study are: Characterize sleep disturbances in SCI cohort using quantitative/qualitative methods. Determine the predictors for SDB and PAP therapy. Assess current practices in treating SCI with SDB in two different health care systems.

43 Study Design PE PFT MEP MIP Using PAP? Follow-up Treated? In-Lab PSG SDB (AHI 5) SCI Cohort Reported SDB? Untreated? Sleep HQ* No SDB (AHI<5) ESS PSQI BQ FSS Inclusion criteria: - >6 months post-sci - Level T6 and above Exclusion: - Pregnant or lactating females - Ventilator dependent or tracheostomy tube in place - CHF or stroke - History of head trauma LOC - Advanced lung, liver or chronic kidney disease - BMI >38 kg/m 2 - Other illness interfere with completion of the study *Sleep HQ: Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin Questionnaire (BQ), Fatigue Severity Scale (FSS).

44 Results(1) Participants Characteristics

45 Sleep Disturbances Characteristics in Chronic SCI Cohort In-Lab PSG SCI Cohort N=28 Sleep Health Questionnaires SDB 79% (N=22*) No SDB 21% (N=6) Response to Followup 90% (N=20) Reported SDB to HCP 50% (N=10) Treated 30% (N=6) Untreated 70% (N=14) Using PAP 66% (N=4) Less than 20% of SCI with symptomatic SDB are on treatment

46 Summary The majority of SCI patients have symptomatic SDB and poor sleep quality. Many SCI patients remained untreated for SDB and have increased cardiovascular morbidities. The lack of awareness and treatment of SDB among SCI patients may represent a form of health care disparity for the disabled. The barriers of care for the disabled (SCI patients) with SDB needs to be addressed.

47 Challenges in the Evaluation of SDB among SCI/D Patients Inadequate recognition among SCI/D patients and providers Underestimation of daytime consequences Erroneous attribution of daytime symptoms Limited access to sleep diagnostic services Difficulties using PAP devices.

48 Confounding Factors Acute vs. chronic Neuromuscular weakness Level of injury Co-morbidities Medications Chronic Intermittent hypoxia

49 It is estimated 1/5 Americans have disability (physical or mental)

50 Inadequate recognition Chart review of two SCI/D programs (VA and private academic systems) ICD codes for SCI (quadriplegia, or paraplegia) were used to identify cases (including traumatic or nontraumatic/ms). All patient >18 yrs old were eligible Outcome: 1- Rate of evaluation and treatment of SDB among SCI/D 2- Rate of co-morbidities: HTN and CVD (MI, CHF, or CAD)

51 Evaluation of SDB in SCI/D & Cardiovascular Morbidities (N=221) % of patients % of patients Only 11% were evaluated for SDB Less than 5% were treated by PAP More than 50% have HTN 6-20% have CVD (MI, CAD, or CHF)

52 SDB in SCI/D & Cardiovascular Morbidities (N=221) % of patients % of patients Only 11% were evaluated for SDB Less than 5% were treated with PAP More than 50% have HTN 6-20% have CVD (MI, CAD, or CHF)

53 Top causes of death post-sci 53 The prevalence rates of CVD in SCI is 30-50% (able bodied range is 5 10%) Myers J, et al. Am J Phys Med Rehabil 2007;86 Strong relationship between SDB and cardiac medication use Stockhammer et al. Spinal Cord 2002, CVD and respiratory disorders combined are #1 cause of mortality in SCI HL Frankel et al, Spinal Cord 1998

54 Erroneous attribution of Poor Sleep Quality in Patients with SCI

55 Treatment of Sleep apnea

56 Ability to use the PAP device

57 Future Directions Barriers to the diagnosis and management of SDB Limitations of sleep laboratories Validity and reliability of home sleep apnea testing Impact of treatment of SDB Is it a priority? Improvement in daytime function Long term consequences

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